The GPwSI niche MVP: Setting up on your own

Posted on by Dr Simon Wilson

Burn the boats or dip your toe?

In an apocryphal story the Vikings burn their boats on arrival at the New World to force them to focus all in. Are you the type of person to act like this? Or would you feel more comfortable with a gradual exposure, keeping the option of the regular work you know and can return to?

Truth be told a viking funeral but you get the idea. Painting by Frank Dicksee

I think this is very personal and situational. I own part of a medical practice while writing this and so I want niche work to feed towards that practice. I therefore have the assurance of general work always there in the practice, which may slowly ratchet down as niche work ratchets up.

However if I was footloose and fancy free, perhaps I would prefer to set up my own shop for total control. Going all in means you can really devote all your time and energies to this one project – obviously if you other sources of funds to keep you going like savings, partner or a part-time job elsewhere that allows you to focus purely on developing this new niche.

Nope, I’m out of here – setting up on your own

Maybe you just really want a break and a chance to set up on your own. This can be a way to ensure you dedicate your efforts to the one thing – this new niche. This ensures you have very clear differentiation from a seeing-all-comers GP clinic and get known for just this work. You will not have a regular patient trying to squeeze their husband in for a BP check or just the drivers licence form during the niche work you need to focus on. Setting up on your own allows very specific clear branding, marketing and price setting which is only around your niche.

Having a clean break and setting up by yourself also ensures it is very clear that you own all the intellectual property, databases and patient list. This could be less clear working from an existing clinic. This is important if we think long term about selling your niche or business to retire or move on to the next thing. This is why looking at your service contract is important. In older service contracts that were probably more employment models, there could be clauses about the practice retaining intellectual property and geographical restraint of practice if you left. However with the changes to Payroll tax and the improved focus on tenant doctor models being finessed with better agreements, your tenant doctor agreement should not discuss IP or geographical restriction, for fear it turns you into a deemed employee and therefore makes the practice liable for payroll tax.

Setting up on your own may of course have increased costs compared to starting where you are. You will need your own technology, software stack, and place to work. You may need to employ people (administration, nursing). You will need a way to get paid and banking and reconciliation software to allow business banking and tax reporting. You may need to buy specific equipment, some so expensive that you need chattel loans to support you. These costs relate to some of what I discussed in the training/costs section – are there some calculations you can devise that assess what revenue you need from patients to make this all worth while? If you are going to need a loan, the bank will want to see a business plan that surveys the current area/market, expected revenue, opportunities for growth and assesses risks.

The GPwSI Niche MVP: Inside a current practice, or on your own?

Posted on by Dr Simon Wilson

Where do you see yourself seeing niche patients? Is this work going to grow out of our exisitng clinic? Is this work going to be at a larger dedicated facility – emergency, cardiac testing? Are you going to start your own bricks an mortar practice? Are you going to start a mobile service – visiting nursing homes, new mothers? Are you going to have a fully virtual service like coaching, mental health, health advocacy?

Bricks and mortar
Bricks and mortar? Or the new digital real estate?

Sometimes the answer is obvious – an interest in correctional medicine is going to be at a jail. An interest in emergency medicine is going to be at hospital of some type (although technology is changing this – look at the Virtual ED work the Northern Hospital in Melbourne is doing). Getting involved in cardiac stress testing, tiltable testing or sleep studies is going to be at a facilty with these types of infrastructure. A surgical niche is going to need an accredited clean and safe location, maybe with the ability to process and sterilise instruments. After this however, things can get more flexible and ripe for innovation. One of the great things to come out of the covid pandemic was the more rapid adoption and confidence with telehealth. Many niche practitioners are now working purely on a remote basis for their niche, from home, practice or from a co-working space.

There are real benefits to starting in your existing practice

Working in your existing practice speaks to the the MVP idea – the walls, heating, power, software, booking and billing software is all there and working so you can focus on the niche and bringing in your ideal patient. There is already a safety net here as well – even though you may not feel delighted with seeing all comers with coughs and colds, paperwork and GANFYD requests, it is a reliable income that can sit there propping up your cash flow while your niche builds. There are also doctors in the practice who are easy to reach to educate about your developing niche and send patients to you. Reception can direct these patients to you. These patients are also warm contacts – they hopefully know, like and trust the practice and so will be happier to come to you as the new skin cancer doctor rather than be interested in seeing someone unknown at the Mole Photography clinic down the road.

Your own clinic will have a lot of processes and databases already – address books, results management, recall systems, billing systems.

Depending on how pro-active your clinic ownership team is, there could be funding to support a new website, equipment or marketing. Caution there that they may feel they own any marketing or website assets created which would be difficult if you wanted to set up on your own and move on.

The exisiting practice will have a physical location and therefore is perfect for Google My Business listings which is important for obtaining reviews. Although not impossible, this is harder with virtual clinics.

Problems with developing a niche in the existing practice?

There are downsides to developing a niche in your own clinic. Chief here can be differentiation and blurring of roles. You start offering your niche in MHT, but consultations blur with the pt also asking for this carer form to be completed. You set your prices to reflect the extra work you have done to develop in a niche but your regular patient does not see the value in paying you for this time and tries to shoehorn every thing into a regular appointment. You are trying to develop patient aids, website to support your niche but keep getting interrupts for Mr K’s webster pack prescriptions.

You can get around this, often by compartmentalising the work – for examples skin checks are only on Saturdays. This may require a new clinic to be set up in your booking system to only allow this one type of consultation at this time. You may want to have discrete pricing and time for your niche – “new peri-menopause appointments are 40minutes and cost $266”

One thing the booking systems don’t seem to be able to offer so far is quaratining your calendar screen for different sorts of appointments. So on a given Tuesday morning, cough and cold patients can book all the slots and your ideal patients may not be able to book in.

There could be marketing differentiation problems as well. Local SEO is greatly aided by Google My Business profiles. If the original clinic owns the GMB profile for that address, are they going to be happy with you establishing a GMB profile at the same site (it can be done, just needs buy in by the original practice).

Google My Business logo

Reviews on Google are essential. Will the main practice allow or set up a GMB for your niche area so that reviews can accumulate there, separate to the main clinic. If doing this you need a way to prompt/ask patients for reviews that only relate to your niche set up, not the main clinic. Some of the automated review requesting systems like HotDoc will send a SMS after the apptointment, asking the patient for a review – this will link to the main clinic google listing. So if you desire reviews for you niche service at the same location, you will need a QR code or link that takes the patient to your niche review GMB, not the main clinic. You may need to ask the main clinic to turn off their automated review asking service.

If there are expenses – marketing materials like website, Facebook or Google advertising, equipment who is paying? Who is claiming the business cost in tax? Who owns the intellectual property you have developed in patient information, workflows, videos? This is important long term if you move, the main practice sells or you want to sell your niche.

There is a 3 page PDF here to help you settle on your niche

The GPwSI niche MVP: Medical Indemnity

Posted on by Dr Simon Wilson

Depending on your niche, your medical indemnity provider may have an interest in your work. This is less likely when your niche is an expansion and deep dive in a counselling or consulting space related to ususal GP practice. For example A&OD support,lactation consultant, ADHD coach, Diabetes support. These niches are an expansion of well understood work any another GP will already provide at a shallower level. You niche down in this area and provide more information and support to the patient but without procedural risks.

The insurer is more likely to be interested the more procedural your work – varicose veins, skin cancer, vasectomy, aesthetic medicine. Here the risks for complications can be high and dramatic – think a surprise pregnancy, a disfiguring facial scar or a local anaestheic overdose. Sometimes there can be a standard of care or defined training course that gives you and your insurer certainty. Sometimes there is no specific course or guideline. Your insurer is going to be reassured with audits demonstrating that your work falls in with expected or published success/complication rates and that you maintain CPD in your area.

For example with my vasectomy work, I have had risk management sessions (outside of any claims) with my insurer where we sat down, reviewed my consent process, forms, workflow and audited complications. I am able to demonstrate CPD in this area. This has improved my confidence in providing this service and my workflows. I know if there ever was a claim, that I am working in this area would not be a surprise to the insurer as it has been fully disclosed and I know I have coverage. I do not know if these risk review meetings have reduced or affected my premiums.

There can also be a middle ground – areas where insurers have come out and said this is fine, this is part of normal practice – for example with provision of MTOP and IUDs.

Avoid underinsurance, incorrect category

As with any insurance, there is one very bad time to find out you are underinsured – when you need to claim! Far better that you keep your insurer abreast of all changes to your practice, current total billings and about any concentration of work. Insurers may have specific rules to follow. For example some insureres place restrictions on the size of skin cancer defects such as less than 15mm on the face, 50mm on the body or might restrict some types of grafts. In researching this I was amused to find I have coverage for post-mortems! Not much chance to practice those thankfully.

So do tell your insurer what your total billings are, they may ask what proportions your work is currently and if proportions will change.

Reduce your niche medical indemnity risks

As you develop your niche more you may see more complex cases or be working on the edge of where specialist colleauges work. Case selection becomes essential here, to know how and when to bow out and refer on. Much of GP procedural work is like this where it is always easier for a solicitor to ask “why didn’t you refer to a specialist plastic surgeon/dermatologist/urologist?” Patients far prefer to see us as they may already know and trust us, we often have better availability and lower prices that specialists. We just can’t let that eagerness to help the patient lead us into taking on unsuitable cases. It is very patient dependant as well. The old ex-shearer in your practice would rather you have a crack at their large BCC, even if you have the text book open on the bedside beside them than trek off to see a plastic surgeon in a glass tower. However the 35year old real estate agent who does all their own tiktok videos may be a great one to refer on.

Have a risk review interview with your insurer, ask then to review your consent form if it is an in-house form. Have clear information for patients, clear expectations for treatment. Be aggressive about supporting any patient with difficulties or complications.

The GPwSI niche MVP: Training/accreditation

Posted on by Dr Simon Wilson

Training/education/certification?

Training and accreditation for a GP niche – what do we need to be safe, effective without spending all the savings to complete?

We do differ from the tech bros around the MVP and fail fast models they promote – we engage with peoples health and we have legislative and medico-legal frameworks to work in. Sometimes this does need to be taken into consideration in your niche.To do the right thing by the patient you need to be safe to work in the area you aim for. Unfortunately we have seen in Australia the consequences of doctors over-reaching their skills and capacity to assess safety – particularly in the aesthetic medicine space. This has led to very negative outcomes for patients and censor and registration, cancellation or restriction for doctors. Longevity in practice is your greatest asset and something you hope niche work supports by reducing burnout risk. Don’t let it risk your career.

aircraft interior with small black sign saying "Don't do anything dumb"

Depending on you niche, there may be craft groups, professional associations or educational groups that you can look to for assessment about training or certification needed.

For some niche work the focus is a deeper dive into usual GP – MHT, paediatrics, FPS and as a result self directed learning, conferences and reading widely may be perfect for developing your niche. For other work that could be a departure from regular care or seen as work encroaching on specialty care – phlebotomy, advanced skin cancer grafts and flaps, thread facelifts you may desire certification to reassure your self you have been assessed safe to work, your indemnity insurer and your patients.

We are fortunate in Australia that much of our extended care work is self-assessed. We should be wary of a UK model where anything outside of sitting down for consultation requires certification and referral and there are several layers of bureucracy involved in a good deal of care. See this screeshot below about how GP surgeries can not provide ear syringing for wax:

Screenshot of ear syringing being ceased in UK GP surgeries
https://www.earhealthservice.co.uk/post/why-gp-surgeries-no-longer-provide-ear-syringing-what-you-need-to-know

I am writing about what I know – supporting general practitioners who already have their fellowship with niche work. Attaining the RACGP or ACCRM fellowship really opens the door to easier private practice than only holding general registration in Australia. Speciality GP registration means access to MBS items via a provider number so the patient can have a rebate, indemnity support and ongoing CPD is smoother. There is now more flexibilty with divers CPD homes now available but membership of one of the GP colleges does give more access to resources, political might and support.

Access to specific niche MBS or medication items.

In Australia, Medicare also provides some guidance in that some Medicare rebate items or prescription privileges are only accessible by certain speciality groups or after training – S100 HIV prescribing, Opiate Substitution training, FFS psychological items, non-directive pregnancy training.

Matters can change here with time – when introduced, Medical Termination medication prescribing required a online course and registration, now it is unrestricted. In Victoria, you have have up to five patients with suboxone substitution without doing extra training.

Watch this space around access to ADHD diagnosis and initiation of stimulant medications being offered to GPs in the future – there is enough public frustration with access that I would not be surprised if this happens for adults.

Hands on training, apprenticeship models, mentoring

Like much in medicine, this niche work can be apprentice model in training. This mentor may engage you with other practitioner in this area – particularly important for small niches like phlebectomy, circumcision which has a small pool of practitioners. With large niches such as skin cancer, psychological medicine, lifestyle medicine there is a plethora of conferences and courses to complete and demonstrate competence.

In this podcast, Dr Moz describes spending a lot of time and money to access further training and education around skin cancer care, both formal courses and assisting with plastic surgery lists.

Does the patient expect or want you to have a raft of post-nominals? I think this is hard to assess. I feel more important is how you describe your work, demonstrate your communication style and relate to the patient. Of course patients expect you to be competent at the work you are offering but come at this without being able to assess this before you have helped them. This is where educational video, clear booking and appointment processes, financial consent and reviews allow the patient to know, like and trust you even before your initial meeting.

Of course a very important factor to discuss around a niche and certification or training is cost. This can be significant to complete a masters of skin cancer, some of the coaching and psychology courses. Some models can even be predatory – historically trainers for circumcision have training contracts that charged a high premium and then garnished future earnings.

There may be nudges from government or other bodies that support or provide training in areas they want more practitioners – Drug and Alcohol training is often paid for and recently the commonwealth via the RACGP has been paying $1200 extra to undertake and complete A&OD training. The Section100 HIV and Hepatitis prescriber training is funded. The Cancer Council has had programs for rural practitioners to access dermatoscopy training and be given a dermatoscope.

Money of course is not everything and some people would pursue a niche even if they did not get paid but there should be some consideration of return on investment before training. Around thinking about expected income, this becomes like a business case plan for income:

  • How many patients do you expect to see?
  • What is the income per niche patient?
  • What is the demographic and expectation of growth of this niche

Therefore is the niche worth exploring and providing from the training costs perspective? A hard headed assessment could mean you avoid spending on a course that does not pay for itself. For other other people they are going to be happy if the new niche makes less income than their regular practice, if it meets that 20% of their golden zone that prevents burnout. Burnout is our greatest financial risk so anything that allows long term engagement with medicine is a win, even if the niche is less per hour that your existing consulting.

Click here for a three page pdf helping you explore what sort of niche you would fit

The GPwSI/GPwER niche MVP

Posted on by Dr Simon Wilson

How

Okay, you have decided that this niche is worth pursuing – what are the next steps? How can you move from the regular consulting life to create some space to build this new venture?

Let’s talk about the bare necessities to get going, where (usual practice, remote, standalone), training or accreditation required, costs and technology stack

The MVP

The Minimum Viable Product – a term invented or popularised by author Eric Ries in his book the Lean Startup. What is the simplest form that allows you to get moving and serving people in your niche? An MVP is important as it allows you to explore this area without great loss if it turns out not be for you, or offer the rewards you imagined.

Book cover of the Lean Startup by Eric Ries

When I was transitioning from rural practice burnout to urban practice I tried on a couple of areas to see if there was a fit for me. This was around in situ simulation and Point of Care Ultrasound. My websites from these projects are still up albeit with very infrequent updates! I tried on these areas like a new outfit but found that they did not offer me enough – interest, reward or challenge. I tried these ideas while still working in my main general practice and stopped them before receiving any income related to either area.

The MVP idea prompts you to think about how to get going with this project without unnecessary trims and finery. You don’t need a wrapped car or a bespoke linen business card – you need a web presence, a way for patients to be booked, seen and billed. Another idea taken from the same startup world as Eric Reis is fail fast – the idea that you test an idea and if it breaks you end it quickly and move on to the next idea. I have previously had websites and was focusing on in situ simulation in general practice and Point of Care Ultrasound in GP, but areas that I started developing but did fit me. Thinking about this relates to the ideas above where you thought about what success looks like. Is it worth setting a time or budget you will give yourself to try this niche before pulling the pin and exiting to the next opportunity?

Click here for a downloadable pdf to prompt you about your ideal niche

What would success look like for you?

Posted on by Dr Simon Wilson

What will success look like? When will you know that this new venture is working well and meeting your goals – be that financial, time, helping your ideal patient? Will it be the first billing of a particular item number specific to your niche?

Winston Churchill quote: Success is not final, failure is not fatal: it is the courage to continue that counts

For me a feeling of success with my vasectomy work was when I was spending 20% of my time with my ideal group – men seeking vasectomy, either discussing and educating or providing vasectomy. It took a good deal of time, focus and work to get there however there are benefits. I can tolerate a lot of midweek GANFYD and declined referral from the big hospital consults with the knowledge that on Friday I have a solida day of procedures, helping couples out and practising a nice moderately technical procedure that I am good at.

So what is success for you? Maybe is is seeing your overall income increase by a certain%. Maybe it is seeing any income that is not from fee for service consulting but is from some one to many work you do – lecturing, downloaded assets you built, consulting to business.

Maybe it is seeing less of the wrong type of patient for you. Don’t fret on this – there is the perfect doctor out there for this patient that does not gel with you, now they are free to find them.

Depending on how granular you desire to be about this goals, some benchmarks or Key Performance Indicators might guide you. Such as the number of your ideal pt in a week, billing a particular item number a certain number of hours in your ideal work. Taking a snapshot of where you are now and where you aim for would help you feel progress is occurring. As we know without a goal we have not direction. By discussing with others we can make this goal real and bring some accountability to the process. Could you be part of a discussion/coffee group that are also working on their niche? This can bring accountability but also mutual support and encouragement.

What is the reward for this aimed for success? The satisfaction of a job well done? That bicycle/clothing/shoes you have been coveting? A special meal or bottle of wine?

If you would like a prompt to help think about your ideal niche, I have a three page pdf here to download

Niche case study – Skin Clinic Website

Posted on by Dr Simon Wilson

For us, our new skin clinic is inside an existing medical practice. This existing practice has a website. However for clarity, differentiation and SEO reasons, we created a standalone website for the skin clinic.

We are doing this as owners for these reasons however if you are not an owner then setting up your own website is still an excellent idea for a number of reasons: You have control of design, you have control and ownership of intellectual property (check any work contract!) and it gets you familiar with working on websites. You need some basic skills, even if you have the website built for you.

Next you have to decide about self built, self built using a theme or paying to have it built. I have done all three. The first version of my vasectomy website was built from a theme and worked okay, once numbers built up a bit and I wanted to compete with the big players however I paid a decent amount of cash ($7000 four years ago) for a great looking site. I built the first version of our practice website from blank WordPress, had it re-built professionally which did not help and now run a slighly improved version of the re-built website. For our skin website I paid for it to be built from a company suggested from social media.

Image of our skin clinic GP niche website
Our new skin clinic website home page

Which option is right for you? If you have the time, creating the website, even one that uses a template like WordPress, Square or Wix will give you the best understanding of how a website works. Like knowing how to use Word or Excel, I think these are great basic skills.

For my first vasectomy website, I went to a conference, skipped most of the lectures and stayed in my room and wrote the website over a weekend!

If your project has the budget, paying for a developer to create the website can result in a good looking website, at the expense of money but also time – there will be lots of backwards and forwards with the developers reviewing, editing.

I would suggest getting going is the most important thing so champion creating a site from one of the services like WordPress/Wix/Square to get you going, get some income coming in and if needed you can pay for a better version down the track.

AI builders? Watch this space with machine learning enabled website builders – Bubble, Webflow and other that are coming along that will hopefully continue to reduce friction with building a site (although introducing platform risk – that your website is tied to their service and fees).

Niche Case Study – New Skin Clinic – domain name

Posted on by Dr Simon Wilson

What are we going to call the new clinic? We want it to be obvious and we want it to be separate to the main clinic website. Why is this? I feel there is more clarity with having a stand alone website. It allows clear messaging, maybe different branding appearance, maybe different pricing structures.

So I created some names. I then checked these against a web host to see if they were available. I discarded the ones that were already in use or not available and this sheet lived in a tea room for a couple of weeks until we had a winner.

My approach is to register the domain name myself. If you are using a full service website builing service like Wix, Squarespace or other, they will also offer to register the domain name for you.

As I have a few domains, I just keep them all together at one site. I use GoDaddy but others I’m sure are great. If you name uses .com.au you will need an ABN. The ABN does not have to be directly related to the new niche website, I presume it is just to ensure you are a genuine Australian entity.

Super! We now have a name and have the domain. What to do with it? We can use the domain to create an email and a website.

For the website you need to decide if it will made for you versus crafted by you. This depends on your time, funds and inclination. I have made simple websites using WordPress themes. Design is not my strong suite however so things are functional but not the most beautiful. For the skin clinic website I paid to have it made, but with maintenance and hosting organised by myself. Other website providers will be full service – building and maintaining for you. For my vasectomy website which needs to look great and work well, I paid for building, hosting, maintaining and ongoing updates.

This website is built in WordPress, hosted at Relentless Hosting. Really it is all about what you start with, what you know a bit about.

I do think the more you control yourself the better off you are. Software people talk about platform risk – that you go too far in with one provider and all your eggs are in their basket. This also applies to whether you or the practice should build this. Again I champion you having all the control and Intellectual Property. Do check any service or tenant agreement you have with a practice about IP and who holds it.

I would caution against spending thousands on a huge website – we want a Minimum Viable Product – something to get out there soon, test the waters and see what happens.

Case study – new skin clinc

Posted on by Dr Simon Wilson

Two doctors in our practice want to increase their work in skin cancer detection and prevention. I want to support them in this niche. Lets follow along as we help them develop this work.

Who do the doctors want to serve? They are for patients with a skin spot to examine, or patients with a history of skin cancer or significant sun exposure in our database who desire a focused skin examination.

The desire was to set this up, clear of usual bookings so the doctor has time, focus to be in the skin check zone.

Initially we set up a skin check clinic in our online booking system, HotDoc.

HotDoc booking system skin clinic niche for GP

We notified people of the skin clinic via our newsletter and adding to the website. So far, we have not spent any money, just done things inhouse.

In subsequent months newsletters we have continued to mention the skin clinic and it is available on the HotDoc booking platform.

Next steps will be a custom website, for which we need a domain name and a GoogleMyBusiness entry for the skin clinic – I’ll follow with these as we develop!

You can’t sell a secret

Posted on by Dr Simon Wilson

“you can’t sell a secret” have you heard that saying before? I have been surprised before when a regular patient has mentioned that they went elsewhere an extra service that our clinic offers. This is no fault of the patient but ours – we were not clear to the patient what services we offered.

I heard this first on a podcast with Nathan Barry who created ConvertKit

If you offer extended skills and special interest care in your clinic, patients much prefer to stay with you, you just have to tell them about the service!

At our practice we have had two new doctors join who would like to expand their skin cancer care work. I have been working on this, using some of the ideas from promoting my vasectomy work. We have been updating Google My Business, we are creating a stand alone website and have been active in the montly newsletters about skin checks.

I have been surprised, although maybe I should not have been that patients I have seen for years have mentioned they are going to book for the new skin check clinic, never having asked me. I obviously had not offered this, not made it clear it was something we could easily do and so the patient did not see it as part of the menu of services they could get from me.

How to help the patient know your offers? There has to be multiple reminders – on your website, on your booking system, posters, newsletters and push notifications like SMS or in-app, depending on your booking system. If other doctors refer to you for your niche there needs to be clear information for them about what you offer and the reminder you will send them back to the original doctor when the task is completed. Lots of letters back help here.

The patient is not you – just because you think email marketing, social media does not work or is annoying, the patient does not need to think this. The patient has a problem and wants to be provided with the solution.

How will you make it crystal clear what you offer?